Introduction
Maternal near-miss (MNM) is recognized as a new concept and has emerged as an adjunct to investigation of maternal deaths as the two represent similar pathways. A conceptual model that had helped us to explain the underlying preventable causes of MNM by examining three phases of delay on maternal healthcare utilization was developed by Thaddeus and Maine. By identifying and reducing the three delays, we will have the greatest impact in reducing MNM and hence maternal deaths.
Aim
The aim of this study was to describe the extent, main types, and contributed factors for three delays in care associated with MNM among women admitted in Women's Health Hospital, Assiut University, Egypt.
Methods
A prospective case–control study was conducted over a period of 1 year from 1 May 2014 to 30 April 2015 at Women's Health Hospital, Assiut University; 342 MNM women and 684 age-matched control women were included in the study. The criteria we used for the identification of MNM were generally based on the presence of different levels of organ dysfunction, which have been identified as recommended by WHO. Data were collected through two approaches: record review and direct interview before discharge. Delays experienced by the study population were collected according to the three-delay model of Thaddeus and Maine.
Results
A high proportion of the MNM group had experienced delay irrespective of the type, with statically significant differences from their controls. Nearly 50% of near-miss cases were more likely to have experienced two or more types of delays compared with 7.7% of controls. Financial problems, fear of being maltreated in hospitals, lack of awareness about signs of obstetric complications, lack of participation in decision making, lack of antenatal care, negative attitude of healthcare worker, and lack of blood availability were associated with delays among MNM cases compared with controls. Having experienced third delay within the intermediate facilities (referral status) was the highest significant predictor that contributed to MNM by delay types.
Conclusion and recommendations
Third delay experienced by the women within the intermediate facilities (referral status) was the most prevalent delay among studied women. Reformation of healthcare system on multiple levels and improvement of the socioeconomic status of women are necessary in Upper Egypt to overcome causes of delay among MNM cases.

Background
Chronic obstructive pulmonary disease (COPD) is an increasingly common disease among older adults that has been linked to other comorbid conditions with serious morbidity and mortality, including cognition impairment. However, it remains poorly understood in COPD.
The aim of the study
The aim of this study is to evaluate cognitive dysfunction in COPD and to relate it to the severity obtained from spirometric and gasometric evaluation of COPD patients.
Patients and methods
In this case–control study design, 25 COPD patients and 25 age-matched and sex-matched healthy control patients were compared. Wechsler Adult Intelligence Scale-III (WAIS-III) and Mini-Mental State Examination (MMSE) were used to evaluate cognition in COPD patients.
Results
There was significant impairment of MMSE with a cognitive dysfunction reported in 72% of the COPD group. There was significant impairment in all components of WAIS-III, namely the verbal IQ, performance IQ, total scale IQ, and deterioration index in the COPD group than in the control group.WAIS-III scale was positively correlated to both oxygen tension and saturation, denoting the utmost role of hypoxemia in the pathogenesis of cognitive dysfunction in COPD patients. Receiver operator characteristics curves were plotted for the use of both oxygen tension and saturation, denoting good use of oxygen tension and saturation as a predictive value for impairment of MMSE and WAIS-III scale and hence cognitive dysfunction.
Results
Cognitive dysfunction is a fixed finding that occurs in the course of COPD. Hypoxemia seems to play the principal role in cognitive disorders. Spirometric parameters seem to be closely related to the progression and prediction of the course of those disorders.

Introduction
Peripheral neuropathy in chronic obstructive pulmonary disease (COPD) has received scanty attention. The purpose of this study was to evaluate objectively the functional changes in the peripheral nervous system in COPD by different electrophysiological parameters and to determine the frequencies of these changes in patients with COPD.
Aim
Assessment of peripheral nerve conduction by evaluation of the motor and sensory nerve conduction (SNC) in COPD patients.
Patients and methods
In this case–control study, we recruited 25 COPD patients and matched 25 healthy controls. Motor and SNC studies for ulnar and median nerves were evaluated by means of electrophysiological nerve study. Motor nerve conduction velocity and sensory nerve conduction velocity (SNCV), distal latencies (DLs), and amplitude of compound motor action potential were recorded. Arterial blood gases including partial pressure of oxygen and carbon dioxide (PaO2and PaCO2), oxygen saturation (SaO2), and arterial pH were measured. Pulmonary function test was done and forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio were measured.
Results
There was a significant difference between COPD patients and the control group in all spirometric and gasometric parameters recorded, except for the arterial pH. On studying motor nerve conduction through median and ulnar nerves, there was an increase in DL, decrease in motor nerve conduction velocity, and longer F-wave latency in the COPD group than in the control group in both nerves. SNC study of the median nerve revealed a decrease in SNCV and an increase in DL in the COPD group than in the control group. Median nerve motor neuropathy was proved in 28% of patients, ulnar nerve motor neuropathy was proved in 36% of patients, whereas sensory nerve study of median nerve proved that 68% of patients have sensory axonal neuropathy and 12% have demyelinating sensory neuropathy. Median nerve Distal Latency (DL) shows negative correlation with FEV1and FEV1/FVC ratio. SNCV of the median nerve was positively correlated to oxygen tension level.
Conclusion
The incidence of neuropathy is high. The rate of axonal neuropathy was significantly higher than other types. Our study showed a significant positive correlation between the degree of hypoxemia and severity of neuropathy, whereas it showed negative correlation between spirometry parameters (FEV1and FEV1/FVC ratio) and median nerve DL.

Background
Right ventricular pacing (RVP) during supraventricular tachycardia (SVT) produces progressive QRS fusion before the QRS morphology becomes stable. This transition zone (TZ) may provide useful information for differentiating orthodromic reciprocating tachycardia (ORT) from atrioventricular nodal re-entrant tachycardia and atrial tachycardia independent of entrainment success.
Methods and results
We studied the effect of properly timed RVP on atrial timing during the TZ in 63 patients with SVT who had RVP within 40 ms of the tachycardia cycle length. The TZ during RVP includes progressively fused QRS complexes and the first paced complex with a stable QRS morphology based on analysis of the 12-lead ECG. We also measured the stimulus–atrial (SA) interval from the end of the TZ and with each QRS complex thereafter until pacing was terminated or ventriculoatrial block occurred. A fixed SA interval was defined as variation less than or equal to 10 ms during RVP. Atrial pre-excitation, postexcitation, or SVT termination with abrupt ventriculoatrial block was observed within the TZ in 19 of 22 patients with ORT. A fixed SA interval was established within the TZ in 22 of 22 patients with ORT. At least one of these two responses was observed in all patients with ORT. Only four patients out of 36 with atrioventricular nodal re-entrant tachycardia showed atrial pre-excitation within TZ and only four patients showed fixed SA within TZ. None of the atrial tachycardia patients had atrial timing perturbed or a fixed SA interval established within the TZ.
Conclusion
During RVP within 40 ms of the tachycardia cycle length, ORT is the likely mechanism when atrial timing is perturbed or a fixed SA interval is established within the TZ.

Background
Psoriasis is a common autoimmune skin disease characterized by intense proliferation and abnormal differentiation of keratinocytes. Recently, some microRNAs (miRs) have been proven to show an aberrant expression in psoriasis and may play a role in the pathogenesis of the disease.
Objectives
The aim of this study was to detect skin miR-369-3p levels in patients with psoriasis and its correlation with disease severity with measurement of one of its regulated psoriasis-related genes, SIRT, and to find the correlation between the studied parameters.
Patients and methods
Skin tissues were collected, and skin miR-369-3p and SIRT1 gene levels were measured. The Psoriasis Area and Severity Index scores of patients and the correlation with skin miR-369-3p levels were evaluated. Correlation between miR-369-3p and SIRT1 gene was also evaluated.
Results
Skin miR-369-3p levels were higher in patients with psoriasis than those in healthy controls (P = 0.01). Skin miR-369-3p had an insignificant positive linear relation with Psoriasis Area and Severity Index scores in psoriasis patients (r = 0.079, P = 0.772). Insignificant negative correlation was found between miR-369-3p and SIRT1 gene levels in skin.
Conclusion
The expression of miR-369-3p is increased in skin tissues from psoriasis patients. Further studies are needed to clarify the role of miR-369-3p in the pathogenesis of psoriasis.

Objective
Dysplasia of lateral semicircular canal (LSCC) is a common inner ear anomaly that may exist in patients with sensorineural hearing loss (SNHL). The diagnosis of subtle anomaly is limited when depending on visual inspection alone to evaluate images. Our purpose is to prove that routine measurement of the bone island of LSCC can avoid missing subtle anomaly and to prove that MRI is a valuable tool in diagnosis.
Patients and methods
This is a retrospective study performed on 67 patients with severe to profound SNHL and on 12 patients with tinnitus. Patients were classified into the control group (46 ears of 34 patients), which had normal MRI findings by visual inspection (24 ears of the 12 patients with tinnitus and 22 normal ears of 22 patients with unilateral SNHL), and the SNHL group (116 ears of 67 patients), in whom inner ear structures were apparently normal in MRI. Patients with isolated vestibular aqueduct (VA) dilatation and patients with Mondini deformity were included in this group. We measured the transverse and the anteroposterior (AP) diameter of the LSCC bone island in two to three contiguous axial images. The width of VA at its midpoint and at its distal end was also measured. SPSS, 16.0, for windows, standardized Student's t-test and Pearson's correlation coefficient were used for statistical analysis.
Results
There was no statistical difference in the bone island width or AP diameter in correlation to the age (P > 0.05). In the SNHL group, the width of the bone island was less than 2.8 mm in 18 (15.5%) ears, whereas the AP diameter was less than 2.8 mm in 21 (18.1%) ears. The bone island width and AP diameter tend to be smaller in patients with dilated VA than in patients with normal VA (P < 0.001). Significant negative correlation was found between the VA width and the bone island width (r = −0.41) and the bone island AP diameter (r = −0.42).
Conclusion
Developing normative radiological measurements by each institute and routine measurement of the bone island of LSCC are essential to avoid missing subtle anomalies by visual inspection alone.

Background
Infliximab (IFX), a monoclonal anti-tumor necrosis factor-α antibody, is commonly used for the treatment of moderate-to-severe inflammatory bowel diseases. No sufficient data are present for its role in the treatment of ulcerative colitis (UC) in our area. We studied the efficacy and safety profile of IFX in treating patients with refractory UC.
Patients and methods
This prospective study included 48 adult patients with refractory UC. They received IFX (5 mg/kg) intravenously at weeks 0, 2, and 6 at Farwaniya Hospital, Kuwait, between 2013 and 2016. Patients were followed-up for 12 weeks and re-evaluated for clinical and endoscopic response to therapy.
Results
With the exception of four patients who were excluded from the study because of serious side-effects, 44 patients completed the study. At week 12, clinical remission and colonic mucosal healing were achieved in 29 (65.9%) patients after initiating IFX treatment. Of these 29 responders, no relapse occurred. No serious adverse events or mortalities were recorded during the course of treatment among the studied patients treated with IFX.
Conclusion
IFX is a safe and efficient therapy that may be useful for induction of remission in patients with refractory UC.

Background
The hypothalamus regulates body homeostasis by mediating endocrine, autonomic, and behavioral functions. Maternal diabetes constitutes an unfavorable environment for embryonic development.
Aim of the work
The aim of the present study was to detect the effect of maternal-induced diabetes on the structural organization of the paraventricular and ventromedial hypothalamic nuclei during postnatal development.
Methods
In this study, a total of 60 adult female albino rats were used. They were divided into two groups – group I (control group) included 30 adult female rats, and group II (experimental group) included 30 adult female rats in which diabetes was induced by a single intraperitoneal injection of alloxan monohydrate. Hypothalamic specimens of the offspring were studied at day 1, 21 days, and 2 months of age postnatally. Several techniques were used in this study, including light microscopy, which included gallocyanine–chrom–alum staining and the Golgi–Cox method, transmission electron microscopy, and immunohistochemistry. In addition, a morphometric study was carried out to estimate the number of neurons in the paraventricular and ventromedial nuclei.
Results
In the newborn, neurons in the studied hypothalamic nuclei showed presence of darkly stained nuclei. With age, these degenerative changes became more prominent. Marked reduction in the extension and branching of dendrites was observed. Electron microscopic examination of 2-month-old offspring of diabetic mothers showed the presence of chromatin condensation with many damaged mitochondria and a marked reduction in free ribosomes. Examination of the presynaptic terminals making contact with the neurons of the paraventricular and ventromedial nuclei showed marked reduction in synaptic vesicles and damaged mitochondria. In addition, an apparent increase in the number of astrocytes was found, indicating an increase in the expression of glial fibrillary acidic protein. The number of cells per area was highly decreased at 21 days and 2 months of age in the offsprings of diabetic mothers in comparison with the control group.
Conclusion
In conclusion, this study indicates that maternal diabetes affects the development and structure of the ventromedial and paraventricular nuclei. These changes suggest that there should be strict control of diabetes before and during pregnancy.

Background
Over one billion Muslims fast worldwide during the month of Ramadan. The impact of fasting on circadian presentation with acute cardiac events is unknown.
Objectives
This study aims to determine whether fasting during Ramadan has any effect on the circadian pattern of acute coronary syndromes (ACS) or not.
Patients and methods
This is a prospective observational study that included all patients with ACS. Patients were divided into two groups based on the history of fasting. Information about age, sex, cardiovascular risk factor profiles, and outcome was collected. The relationship of time of presentation of initial symptoms with fasting and time of seeking medical advice was evaluated and statistically analyzed.
Results
Of the 494 patients with ACS hospitalized during the study period, 85 patients were fasting during Ramadan. Fasting patients were more likely to have their symptoms between 3 a.m. and 4 a.m. (15.3%), whereas nonfasting patients were more likely to have their symptoms between 7 a.m. and 8 a.m. (16.6%) (P < 0.005). In addition, fasting patients were more likely to present to the hospital early within the first hour of onset of symptoms (35.3%), whereas nonfasting patients were less likely to present to the hospital early within the first hour (23.7%). These differences were also statistically significant (P < 0.04).
Conclusion
The changes in food intake and/or sleep timings affect the circadian rhythm and influence the timing of presentation of ACS.

Background
Laryngopharyngeal reflux (LPR) can be defined as chronic symptoms or laryngeal mucosal damage caused by the abnormal reflux of gastric contents into the upper airway. LPR plays an important role in up to 50% of laryngeal complaints that present in the otolaryngeal clinic, and the symptomatology of LPR has more different presentation. LPR is suspected in the presence of symptoms of hoarseness, dysphagia, cough, globus, excessive mucus, throat pain, throat clearing, and laryngospasm. Diagnosis of LPR is confirmed using the following: reflux symptom index (RSI), laryngoscopic examination [reflux finding score (RFS)], and esophagogastroduodenoscopy.
Patients and methods
A cross-sectional study was conducted on 60 patients with typical gastroesophageal reflux disease (GERD) symptoms and laryngeal complaints; these studied patients were recruited from patients who attended the outpatient clinic of Tropical Medicine and Gastroenterology, and Phoniatric Unit, Assiut University Hospital. The symptom questionnaire and the classification proposed by Belafsky and his colleagues (RSI) are used and upper endoscopy is performed for the diagnosis of GERD patients. Nasofibrolaryngoscopy for all these patients was performed to compare the results (RFS). Psychiatric assessment was performed by a psychiatric specialist using symptoms checklist revised 90. Patients with a score more than 60 will be re-evaluated using the following questionnaires: Hamilton checklist of symptoms of depressive illness and Hamilton rating scale for anxiety.
Results
All studied patients showed positive RSI (100%) and diagnostic endoscopy showed GERD in 58 (96.7%) patients, and 32 (53.3%) of them were found to have a positive finding in laryngoscopy; the findings were as follows: vascular congestion and vocal cord hyperemia in 32 (100%) patients, vocal cord edema in 26 (81%), phonatory gap in 13 (40%), subglottic edema in 12 (37%), vocal cord swelling in 10 (31.25%), and contact granuloma in eight (25%). A positive significant correlation was detected between phonasthenia symptoms, mostly lump sensation, hoarseness, throat clearing, and dry mouth (symptoms), and laryngeal finding (RFS), except for difficulty in swallowing saliva. There is a strong association between psychological symptoms and the presence of LPR; the most commonly detected manifestation was anxiety, and there was a positive significant correlation with anxiety and a negative significant correlation between depression and reflux symptoms.
Conclusion
RSI and RFS could be useful for the diagnosis and evaluation of LPR in patients with GERD complaining of laryngeal symptoms. Psychological intervention can improve the general well-being and quality of life of patients with gastrointestinal symptoms.

Background
Lymphedema is one of the most problematic complications after breast cancer treatment. The risk factors (RFs) for breast cancer-related lymphedema (BCRL) are multifactorial and are not fully understood.
Aim
The aim of this study was to determine the RFs for breast cancer-related upper-arm lymphedema.
Patients and methods
This is a case–control study including patients with arm lymphedema as cases and patients without arm lymphedema as controls. The included patients had breast carcinoma (n = 128) and all had operable breast cancer that could undergo locoregional therapy (surgery ± radiotherapy). Diagnosis of lymphedema was made by the measurement method, in which a difference of up to 2 cm either above or below the olecranon process between the two arms is generally accepted for diagnosis of lymphedema. Assessment of lymphedema and RFs was performed by logistic regression.
Results
Univariate analysis showed significant difference between the groups of patients with and those without lymphedema with respect to older age (0.016), BMI greater than 30 (0.007), hard work (0.004), ipsilateral dominant arm (0.021), history of injury (0.001) and infection (0.001) to the ipsilateral arm, positive lymphadenopathy (0.020), advanced stage of cancer (0.009), positive human epidermal growth factor receptor-2/neu receptor (0.001), level III axillary dissection (0.001), and lack of information about BCRL and/or not following prophylactic advice (0.001). Meanwhile, multiple logistic regression analysis showed only old age (0.005), history of injury (0.016), cellulitis (0.033), level III axillary dissection (0.011), lack of information about BCRL, and not following prophylactic advice (0.012) to have a significant relation to lymphedema.
Conclusion
Healthcare personnel and patients must be aware of the prevention and early treatment of lymphedema.

Background
The adequate functioning of the maternal thyroid gland plays an important role in ensuring that the offspring develop normally. Therefore, maternal hypothyroidism and hyperthyroidism are associated with offspring abnormalities.
Aim of the work
This study was carried out to examine the effect of maternal hypothyroidism on the postnatal development of the pituitary–thyroid axis in the albino rat.
Materials and methods
Thirty pregnant female albino rats were divided into two groups. Group I was the control group and group II was the hypothyroid group whose rats were given carbimazole in a dose of 5 mg/rat/day through the intragastric intubation from the gestational day 10 until the postnatal day 20. The offspring of both groups were killed at the ages of newborn, 10, 30, and 60 days. The pituitary and thyroid glands were extracted from the pups of control and treated animals and processed for light and electron microscopy and morphometric analysis. In addition, an immunohistochemical study was carried out on the pituitary specimens for the detection of thyrotrophs.
Results
The present study revealed that the maternal hypothyroidism caused morphological changes in the pituitary–thyroid axis of the offspring. The changes started to appear in the newborn age and persisted throughout the postnatal life. The light microscopic examination revealed shrunken thyroid follicles. The follicular epithelial height increased and was composed of tall columnar cells with a vacuolated cytoplasm. The colloid decreased or was completely absent. Regarding the pituitary gland, there were many large pale vacuolated cells with dark nuclei and sometimes the vacuolation affected most of the cells. The electron microscopic examination of the thyroid follicular cells and thyrotrophs showed ultrastructural signs of an increased activity, which included dilated endoplasmic reticula, well-developed Golgi, enlarged mitochondria, and a decreased number of the secretory granules. Large cytoplasmic vacuoles were also observed. The immunohistochemical study of the pituitary gland revealed an increased number of thyroid-stimulating hormone immunopositive cells. The morphometric analysis of the pituitary and thyroid sections showed a significant decrease in the thyroid follicular diameter and a significant increase in the thyroid follicular epithelial height and in the number of the thyrotrophs per reference area.
Conclusion
From this study, it could be concluded that the experimentally induced maternal hypothyroidism disturbed the pituitary–thyroid axis of the offspring.